Providing prescribers at the point of prescribing accurate copay information can be a challenge with today's healthcare provider systems as healthcare claims continue to evolve. Initially, a patient could expect to pay a single copay amount for all medications. Over time, the financial structures have grown increasingly more sophisticated (i.e. formulary tiers, deductibles, maximum benefits, etc.). Further, for some pharmacy benefit plans a patient has the ability to challenge a formulary status decision. Today, prescribers attempt to determine an accurate patient copay amount by establishing patient eligibility, including association to a specific formulary, downloading formulary information to the healthcare provider device, comparing a proposed medication to the formulary to determine alignment, or writing the prescription and waiting to see if the pharmacy calls with a request for an alternative medication. However, these solutions may be inadequate because they may not reflect the patient's actual out of pocket cost.
This problem may be further exacerbated in situations where an incentive program to reduce patient costs (i.e. patient copay amounts) exists for the medication being prescribed to the patient. An incentive program may include, but is not limited to, a coupon, voucher, rebate, discount, loyalty award, or other equivalent non-insurance benefit or the like that is provided to the patient when the medication is dispensed to the patient. Failure of a prescriber to know about or have access to benefit information for these incentive programs could result in the prescriber not being able to provide accurate copay information to the patient at the time the medication is being prescribed. This may result in the patient having their treatment adversely affected by either requesting a different medication being prescribed (because the patient believes the copay will be higher than it actually is once the incentive program is applied) or the patient choosing not to fill the prescription at all. Providing the prescriber with accurate copay information, including any incentive program information that reduces or otherwise modifies the patient copay amount will allow the prescriber to give the patient copay information that will be the same as that which the patient receives when they fill that prescription at pharmacy.